Copyright 2002, Delmar, A division of Thomson Learning Chapter 3 The Complete Health History Including Documentation

Copyright 2002, Delmar, A division of Thomson Learning Competencies State the purpose of the four different types of health history and provide an example of when each is used. Identify the components of the complete health history. Describe how to assess the ten characteristics of a chief complaint. (continues)

Copyright 2002, Delmar, A division of Thomson Learning Competencies Diagram a patient’s genogram correctly. Demonstrate sensitivity to patients of different races, religions, ethnic backgrounds, sexual orientations, and socioeconomic status when conducting a health history. Conduct a complete health history on ill and well patients and record data.

Copyright 2002, Delmar, A division of Thomson Learning Types of Health History Provides information on the patient’s health status: social, emotional, physical, cultural, and spiritual identity Complete health history Episodic health history Interval or follow-up health history Emergency health history

Copyright 2002, Delmar, A division of Thomson Learning Identifying Information Included in Medical Record Patient name Address Occupation Insurance Phone number (continues)

Copyright 2002, Delmar, A division of Thomson Learning Identifying Information Included in Medical Record Usual source of health care Date of birth Birth place Emergency contact Social security number

Copyright 2002, Delmar, A division of Thomson Learning Complete Health History Patient profile Reason for seeking health care  Chief complaint (CC)  Sign  Symptom Present health and history of present illness (HPI)

Copyright 2002, Delmar, A division of Thomson Learning Ten Characteristics of a Chief Complaint Location Radiation Quality Quantity Associated manifestations  Pertinent negatives (continues)

Copyright 2002, Delmar, A division of Thomson Learning Ten Characteristics of a Chief Complaint Aggravating factors Alleviating factors Setting Timing Meaning and impact

Copyright 2002, Delmar, A division of Thomson Learning Past Health History (PHH) Provides information on the patient’s health status from birth to present Medical history  Chronic illness  Episodic illness  Sequelae (continues)

Copyright 2002, Delmar, A division of Thomson Learning Past Health History Surgical history  Major procedures  Minor procedures  Include year performed, hospital, physician, sequelae (continues)

Copyright 2002, Delmar, A division of Thomson Learning Past Health History Medications  Prescription  Over-the-counter  Herbs  Home remedies  General questions  Dose  Frequency  Side effects  Purpose (continues)

Copyright 2002, Delmar, A division of Thomson Learning Past Health History Communicable diseases  Infectious  Pertussis  Tuberculosis  Hepatitis  AIDS  Sexually transmitted  Gonorrhea  Syphilis  Chlamydia  Herpes (continues)

Copyright 2002, Delmar, A division of Thomson Learning (continues) Past Health History Allergies  Medications  Food  Animals  Environment  Symptoms  Treatment  Complications

Copyright 2002, Delmar, A division of Thomson Learning Past Health History Injuries/accidents Special needs Blood transfusions (continues)

Copyright 2002, Delmar, A division of Thomson Learning Past Health History Childhood illnesses  Varicella  Diptheria  Measles, mumps, rubella  Polio, rheumatic or scarlet fever (continues)

Copyright 2002, Delmar, A division of Thomson Learning Past Health History Immunizations: childhood  MMR  Polio  Smallpox  DPT  Haemophilus influenza b (Hib)  Hepatitis B (continues)

Copyright 2002, Delmar, A division of Thomson Learning Past Health History Immunizations: adult  Varicella  Hepatitis A  Hepatitis B  Influenza  Tetanus  Pneumococcal  Lyme  Meningococcal  Last TB test (date and results)

Copyright 2002, Delmar, A division of Thomson Learning Family Health History (FHH) Records the health status of the patient and immediate blood relatives. Contains age and health status of the patient, spouse, children, siblings, and the patient’s parents. Document information in a genogram and in a list of familial diseases.

Copyright 2002, Delmar, A division of Thomson Learning Social History (SH) Records information about the patient’s lifestyle that may impact health Tips for obtaining information  Establish rapport  Direct eye-contact  Pose questions in a matter of fact tone  Nonjudgmental demeanor  Normalizing (continues)

Copyright 2002, Delmar, A division of Thomson Learning (continues) Social History Alcohol use  Thorough assessment to include:  Quantity of alcohol consumed  Frequency of consumption  Age at first drink  Pattern of consumption  Length of time consuming current amount  History of loss of consciousness or blackouts

Copyright 2002, Delmar, A division of Thomson Learning Social History  Time of day when drinking occurs  Drink alone or with others  Drink and drive  Self perception of drinking CAGE questionnaire (Mayfield, McLeod & Hall, 1974)  Have you ever felt you should cut down on your alcohol intake? (continues)

Copyright 2002, Delmar, A division of Thomson Learning Social History  Have people annoyed you by criticizing your alcohol intake?  Have you ever felt guilty about your alcohol intake?  Have you ever needed alcohol for an eye-opener (morning consumption)? Tobacco use  Pack/year history  Type of tobacco used (continues)

Copyright 2002, Delmar, A division of Thomson Learning Social History  Age started to use tobacco  Quantity used on daily basis  Previous attempts to quit  Self-perception of tobacco use  Live or work with smoker Drug use  Prescription and over-the-counter medications (continues)

Copyright 2002, Delmar, A division of Thomson Learning Social History  Illegal and recreational drugs  Same types of questions used for determining alcohol use Sexual practices, specific questions Sexual orientation Past sexual practice Number of partners Birth control method (continues)

Copyright 2002, Delmar, A division of Thomson Learning Social History Measures to prevent exchange of body fluids Presence of STDs Satisfaction with sexual performance/needs Travel history Work environment (continues)

Copyright 2002, Delmar, A division of Thomson Learning Social History Home environment  Physical  Psychosocial Hobbies or leisure activities Stress Education Economic status (continues)

Copyright 2002, Delmar, A division of Thomson Learning Social History Military service Religion Ethnic background Roles/relationships Functional health assessment  Activities of daily living (continues)

Copyright 2002, Delmar, A division of Thomson Learning Social History Health maintenance activities (HMA)  Sleep  Diet  Exercise  Stress management  Use of safety devices  Health check-ups

Copyright 2002, Delmar, A division of Thomson Learning Review of Systems (ROS) Cephalo-caudal approach Questions  Sign/symptom related  Disease related questions

Copyright 2002, Delmar, A division of Thomson Learning Documentation Guidelines Ensure accuracy  Record information immediately upon completion of patient encounter  Correct patient record or chart  Avoid distractions while documenting  Proofread your entry for accuracy and completeness (continues)

Copyright 2002, Delmar, A division of Thomson Learning Documentation Guidelines Date and time each entry Sign each entry with full legal name and professional credentials Write legibly Use permanent ink (black preferred) Do not leave a space between entries (continues)

Copyright 2002, Delmar, A division of Thomson Learning Documentation Guidelines Use quotes to indicate direct patient response Document in chronological order Document in complete but concise manner using phrases and abbreviations as appropriate (continues)

Copyright 2002, Delmar, A division of Thomson Learning Documentation Guidelines Document telephone calls that relate to the patient’s case Never correct another person’s entry Use a single line to cross out an error, then date, time and sign correction If it is not documented, it was not done

Copyright 2002, Delmar, A division of Thomson Learning Assessment-Specific Documentation Guidelines Record pertinent positive and negative assessment data Document any parts of the assessment that are omitted or refused by the patient Avoid using judgmental language Avoid evaluative statements; cite specific statements or actions you observe (continues)

Copyright 2002, Delmar, A division of Thomson Learning Assessment-Specific Documentation Guidelines State time intervals precisely Use specific measurements Draw pictures when appropriate (continues)

Copyright 2002, Delmar, A division of Thomson Learning Assessment-Specific Documentation Guidelines Refer to findings using anatomic landmarks Use the face of a clock to describe findings that are in a circular pattern Document any change in the patient’s condition during a visit or from previous visits Describe what you observed, not what you did